Provider Demographics
NPI:1588063648
Name:RENNER, JILL
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:RENNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:189 RUTGERS AVE
Mailing Address - Street 2:
Mailing Address - City:MANAHAWKIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08050-2947
Mailing Address - Country:US
Mailing Address - Phone:609-290-2298
Mailing Address - Fax:
Practice Address - Street 1:300 CORPORATE CENTER DR
Practice Address - Street 2:SUITE 100
Practice Address - City:MANALAPAN
Practice Address - State:NJ
Practice Address - Zip Code:07726-8736
Practice Address - Country:US
Practice Address - Phone:732-761-0088
Practice Address - Fax:732-761-2550
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-14
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00742200235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist